foreword - emergencypedia

Instigo Cogito Novo Amplio

Westmead Emergency

Research Unit

Editor

Amith Shetty

Contributors

Margaret Murphy

Naren Gunja

Gopi Mann

Toby Thomas

In this month’s edition –

DUBIUS - Questionable tests

and procedures – P 3

PRIMUS – introducing – BLISS

trial - P4

DISPUTATIO – aggie baggie –

DL versus CMAC – P5-8

NOSTOS ALGOS - Blast from

the past – Discovery of

Penicillin P9

CONCLUSIO – Journal club

articles and department

publications – P10

PRÉCIS MENSTRUA April

2013 – P11-26

Foreword

Thanks for those with encouraging words for this new endeavor.

For those of you who missed last month’s edition - Westmead EMRU

Précis is divided into a few segments and in the interest of EBM, the first

section DUBIUS is dedicated to 5 questionable tests or procedures relevant

to emergency medicine, these are tests and practices that have been found

to lack scientific credibility but yet practiced diligently. PRÉCIS MENSTRUA

outlines the significant research articles of the month gone by or articles

missed out in the recent past. NOSTOS ALGOS features a significant or

maybe not so significant research piece from the past; DISPUTATIO focuses

on a scientific debate around a certain topic or practice – this month we

pass verdict on the Direct Laryngoscopy versus C-MAC debate! PRIMUS

will introduce you to one of the current EMRU research activity occurring

at Westmead ED…

The article has been re-aligned so that the first 10 pages hold the most

critical information in synopsis and the latter pages are for those with

insomnia and itch for more information. Précis will soon be available on

the intranet.

Feel free to send your articles, topics or suggestions to

[email protected] or [email protected] or

[email protected]

Further information or background data (when available) on all topics

appearing on précis can also be requested for further scrutiny.

mailto:[email protected]




In this month, the most important article published (my opinion!) was the updated Cochrane review

on crystalloids versus colloids for volume replacement (all causes – not just sepsis, trauma). So it is

now time to throw out all synthetic colloids – thankfully we have already ceased stocking these in

our ED and I would urge all ED staff to question the use of same by external teams in ED!

You will also find the recently launched acute otitis media management guidelines. There is an

interesting articles associating cardiovascular fitness in the 60s with risk of development of

dementia in this later ages, so get on that bike and push it hard.

There are two very interesting articles in JAMA-internal medicine about the concept of diagnostic

testing in patients with low probability of disease! I advise all clinicians adept in the art of

diagnosing to read these two articles at least once! There is a great meta-analysis and a commentary

article.

Another research article which is causing a lot of ripples in the cardiac community is the use of

chelation therapy in MI patients! I have attached the article abstract as it makes interesting reading

and like faecal transplant therapy may turn out to be a winner in the future but I am hedging my

bets on it yet.

There a few good review articles worth a read surrounding pneumothoraces management

(MEDSCAPE) and also about chest tube selection and insertion techniques (Clinics in Chest Medicine

– MD CONSULT on CIAP). Again great articles for all levels of practitioners.

There is also a great article on the “Medical Marriage” about spouse/partner perception of being

married to a medical professional – moral of the story – stay up longer and spend that time with

them! Also there is a study suggesting avoidance of pesticides during pregnancy to avoid increased

risk to childhood tumours!

An article in the Annals of EM puts the costs of ED overcrowding in patient terms and adds further

impetus for hospitals to find sustainable access block prevention strategies. Also published in Nature

Medicine was an article explaining the increased atherosclerosis risk associated with increased red

meat consumption – so may be ATKINS really paid for his diet in kind!

You will also find a few interesting articles on Ultrasound this month – from its use for LP to a whole

body US protocol… Toby and John will be licking their lips at this prospect!

Lastly, I could not resist but include an observational study about men’s sizes and perceptions by the

opposite – the authors claim that they have found the answer to the age-old dilemma – DOES SIZE

REALLY MATTER?


DUBIUS

Don’t routinely do diagnostic testing in patients with chronic urticaria. In the overwhelming

majority of patients with chronic urticaria, a definite etiology is not identified. Limited laboratory

testing may be warranted to exclude underlying causes. Targeted laboratory testing based on clinical

suspicion is appropriate. Routine extensive testing is neither cost effective nor associated with

improved clinical outcomes. Skin or serum-specific IgE testing for inhalants or foods is not indicated,

unless there is a clear history implicating an allergen as a provoking or perpetuating factor for

urticaria.

Don’t order annual electrocardiograms (EKGs) or any other cardiac screening for low-risk patients

without symptoms. There is little evidence that detection of coronary artery stenosis in

asymptomatic patients at low risk for coronary heart disease improves health outcomes. False-

positive tests are likely to lead to harm through unnecessary invasive procedures, over-treatment

and misdiagnosis. Potential harms of this routine annual screening exceed the potential benefit.

Don’t screen for carotid artery stenosis (CAS) in asymptomatic adult patients. There is good

evidence that for adult patients with no symptoms of carotid artery stenosis, the harms of screening

outweigh the e benefits. Screening could lead to non-indicated surgeries that result in serious harms,

including death, stroke and myocardial infarction.

Don’t prescribe oral antibiotics for uncomplicated acute external otitis. Oral antibiotics have

significant adverse effects and do not prove ide adequate coverage of the bacteria that cause most

episodes; in contrast, topically administered products do provide coverage for these organisms.

Avoidance of oral antibiotics can reduce the spread of antibiotic resistance and the risk of

opportunistic infections.

Neuroimaging (CT, MRI) is not necessary in a child with simple febrile seizure. CT scanning is

associated with radiation exposure that may escalate future cancer risk. MRI also is associated with

risks from required sedation and high cost. The literature does not support the use of skull films in

the evaluation of a child with a febrile seizure. Clinicians evaluating infants or young children after a

simple febrile seizure should direct their attention toward identifying the cause of the child’s fever. 1

1 Adapted from choosingwisely.org an ABIM initiative supported by 21 specialty training colleges


PRIMUS

Bacterial Load in Severe Sepsis trial Background: Severe sepsis is characterised by organ dysfunction secondary to infection, typically caused by bacteria and the early control of infection with antibiotics is a powerful determinant of survival. However, conventional cultures, even when positive, provide no information about infection intensity and no data at all in the critical early hours of therapy. Quantification of bacteria in the blood (the "bacteraemic load") in this study allows us to characterise relationship/s between bacteraemic load, inflammatory response and clinical outcomes (organ failure, death), and to clinically validate an assay that may become standard of care for monitoring severe sepsis. PRIMARY HYPOTHESES: that, in patients with septic shock, (1) the bacteraemic load on presentation to hospital and changes in bacteraemic load over time directly influence survival and organ failure; and (2) bacteraemic load is the primary determinant of host inflammatory response. Methodology Eligibility - all triage 1 and 2 patients with suspected sepsis as identified by ED triage nurse based on the CEC triage tool for sepsis recognition Collection of blood specimens – Cultures + VBG (LACTATE) + PAX GENE tube (photos below) and order tests – send tubes to ICPMR as is usual process Data collection – fill out Sepsis data form – this is a requirement by Centre of clinical excellence (CEC NSW) requirement not part of this trial which will help us monitor our sepsis management performance. Outcome data 28 days and 180 days mortality are primary outcomes. Length of ICU and Hospital stay, Vasopressor free days, Ventilator free days, renal failure are secondary outcomes

Grab SEPSIS trolley→ collect cultures/VBG LACTATE/PAXGENE tube →ORDER BACTERIAL LOAD test →send to lab→ fill sepsis audit form

Why Westmead ED? Outcome of this trial will give us greater insight into developing tools to recognise potentially unwell patients in the future. If data for BLISS is useful then it will help ICPMR develop rapid tests to direct early therapy and management of patients and directed antibiotic therapy could occur long before formal culture results are available.


DISPUTATIO

Direct Laryngoscopy versus C-MAC video laryngoscopy debate

Is the increased cost associated with C-MAC use in ED justified? What does the evidence out there

tell us?

Extremes of views – C-MAC should be reserved for failed attempts and educational purposes versus

C-MAC should be the standard first-line approach for all ED intubations!

Articles of relevance comparing the two instruments in question –

BMC Anesthesiol. 2011 Mar 1;11:6. doi: 10.1186/1471-2253-11-6. A randomised, controlled crossover comparison of the C-MAC videolaryngoscope with direct laryngoscopy in 150 patients during routine induction of anaesthesia. Cavus E, Thee C et al. METHODS: After approval of the institutional review board and written informed consent, 150 patients (ASA I-III) with general anaesthesia were enrolled. Computer-based open crossover randomisation was used to determine the sequence of the three laryngoscopies: Conventional direct laryngoscopy (HEINE Macintosh classic, Herrsching, Germany; blade sizes 3 or 4; DL group), C-MAC size 3 (C-MAC3 group) and C-MAC size 4 (C-MAC4 group) videolaryngoscopy, respectively. After 50 patients, laryngoscopy technique in the C-MAC4 group was changed to the straight blade technique described by Miller (C-MAC4/SBT). RESULTS: Including all 150 patients (70 male, aged (median [range]) 53 [20-82] years, 80 [48-179] kg), there was no difference of glottic view between DL, C-MAC3, C-MAC4, and C-MAC4/SBT groups; however, worst glottic view (C/L 4) was only seen with DL, but not with C-MAC videolaryngoscopy. In the subgroup of patients that had suboptimal glottic view with DL (C/L≥2a; n = 24), glottic view was improved in the C-MAC4/SBT group; C/L class improved by three classes in 5 patients, by two classes in 2 patients, by one class in 8 patients, remained unchanged in 8 patients, or decreased by two classes in 1 patient. The median (range) time taken for tracheal intubation in the DL, C-MAC3, C-MAC4 and C-MAC4/SBT groups was 8 sec (2-91 sec; n = 44), 10 sec (2-60 sec; n = 37), 8 sec (5-80 sec; n = 18) and 12 sec (2-70 sec; n = 51), respectively. CONCLUSIONS: Combining the benefits of conventional direct laryngoscopy and videolaryngoscopy in one device, the C-MAC may serve as a standard intubation device for both routine airway management and educational purposes. However, in patients with suboptimal glottic view (C/L≥2a), the C-MAC size 4 with straight blade technique may reduce the number of C/L 3 or C/L 4 views, and therefore


facilitate intubation. Further studies on patients with difficult airway should be performed to confirm these findings. Ann Emerg Med. 2012 Dec;60(6):739-48.. Epub 2012 May 5. A comparison of the C-MAC video laryngoscope to the Macintosh direct laryngoscope for intubation in the emergency department. Sakles JC, Mosier J et al. Abstract STUDY OBJECTIVE: We determine the proportion of successful intubations with the C-MAC video laryngoscope (C-MAC) compared with the direct laryngoscope in emergency department (ED) intubations. METHODS: This was a retrospective analysis of prospectively collected data entered into a continuous quality improvement database during a 28-month period in an academic ED. RESULTS: During the 28-month study period, 750 intubations were performed with either the C-MAC with a size 3 or 4 blade or a direct laryngoscope with a Macintosh size 3 or 4 blade. Of these, 255 were performed with the C-MAC as the initial device and 495 with a Macintosh direct laryngoscope as the initial device. The C-MAC resulted in successful intubation in 248 of 255 cases (97.3%; 95% confidence interval [CI] 94.4% to 98.9%). A direct laryngoscope resulted in successful intubation in 418 of 495 cases (84.4%; 95% CI 81.0% to 87.5%). When the C-MAC was used as a video laryngoscope, a Cormack-Lehane grade I or II view (video) was obtained in 117 of 125 cases (93.6%; 95% CI 87.8% to 97.2%), whereas when a direct laryngoscope was used, a grade I or II view was obtained in 410 of 495 cases (82.8%; 95% CI 79.2% to 86.1%). The C-MAC was associated with immediately recognized esophageal intubation in 4 of 255 cases (1.6%; 95% CI 0.4% to 4.0%), whereas a direct laryngoscope was associated with immediately recognized esophageal intubation in 24 of 495 cases (4.8%; 95% CI 3.1% to 7.1%). CONCLUSION: When used for emergency intubations in the ED, the C-MAC was associated with a greater proportion of successful intubations and a greater proportion of Cormack-Lehane grade I or II views compared with a direct laryngoscope. Anaesthesia. 2010 May;65(5):483-9. doi: 10.1111/j.1365-2044.2010.06307.x. Epub 2010 Mar 19. Comparison of the C-MAC videolaryngoscope with the Macintosh, Glidescope, and Airtraq laryngoscopes in easy and difficult laryngoscopy scenarios in manikins. McElwain J, Malik MA et al. Abstract The C-MAC comprises a Macintosh blade connected to a video unit. The familiarity of the Macintosh blade, and the ability to use the C-MAC as a direct or indirect laryngoscope, may be advantageous. We wished to compare the C-MAC with Macintosh, Glidescope and Airtraq laryngoscopes in easy and simulated difficult laryngoscopy. Thirty-one experienced anaesthetists performed tracheal intubation in an easy and difficult laryngoscopy scenario. The duration of intubation attempts, success rates, number of intubation attempts and of optimisation manoeuvres, the severity of dental compression, and difficulty of device use were recorded. In easy laryngoscopy, the duration of tracheal intubation attempts were similar with the C-MAC, Macintosh and Airtraq laryngoscopes; the Glidescope performed less well. The C-MAC and Airtraq provided the best glottic views, but the C-MAC was rated as the easiest device to use. In difficult laryngoscopy the C-MAC demonstrated the shortest tracheal intubation times. The Airtraq provided the best glottic view, with the Macintosh providing the worst view. The C-MAC was the easiest device to use. Anesthesiology. 2012 Mar;116(3):629-36. doi: 10.1097/ALN.0b013e318246ea34.


Comparative effectiveness of the C-MAC video laryngoscope versus direct laryngoscopy in the setting of the predicted difficult airway. Aziz MF, Dillman D et al. BACKGROUND: Video laryngoscopy may be useful in the setting of the difficult airway, but it remains unclear if intubation success is improved in routine difficult airway management. This study compared success rates for tracheal intubation with the C-MAC® video laryngoscope (Karl Storz, Tuttlingen, Germany) with conventional direct laryngoscopy in patients with predicted difficult airway. RESULTS: The use of video laryngoscopy resulted in more successful intubations on first attempt (138/149; 93%) as compared with direct laryngoscopy (124/147; 84%), P = 0.026. Cormack-Lehane laryngeal view was graded I or II in 139/149 of C-MAC attempts versus 119/147 in direct laryngoscopy attempts (P < 0.01). Laryngoscopy time averaged 46 s (95% CI, 40-51) for the C-MAC group and was shorter in the direct laryngoscopy group, 33 s (95% CI, 29-36), P < 0.001. The use of a gum-elastic bougie and/or external laryngeal manipulation were required less often in the C-MAC intubations (24%, 33/138) compared with direct laryngoscopy (37%, 46/124, P = 0.020). The incidence of complications was not significantly different between the C-MAC (20%, 27/138) versus direct laryngoscopy (13%, 16/124, P = 0.146). CONCLUSION: A diverse group of anesthesia providers achieved a higher intubation success rate on first attempt with the C-MAC in a broad range of patients with predictors of difficult intubation. C-MAC laryngoscopy seems to be a useful technique for the initial approach to a potentially difficult airway. Crit Care. 2012 Jun 13;16(3):R103. [Epub ahead of print] Endotracheal intubation using the C-MAC® video laryngoscope or the Macintosh laryngoscope: A prospective, comparative study in the ICU. Noppens RR, Geimer S et al. ABSTRACT: INTRODUCTION: Endotracheal intubation in the ICU is a challenging procedure and is frequently associated with life-threatening complications. The aim of this study was to investigate the effect of the C-MAC® video laryngoscope on laryngeal view and intubation success compared with direct laryngoscopy. RESULTS: A total of 274 critically ill patients requiring endotracheal intubation were included; 113 intubations using ML and 117 intubations using the C-MAC® were assessed. In patients with at least one predictor for difficult intubation, the C-MAC® resulted in more successful intubations on first attempt compared with ML (34/43, 79% vs. 21/38, 55%; P = 0.03). The visualization of the glottis with ML using Cormack and Lehane (C&L) grading was more frequently rated as difficult (20%, C&L grade 3 and 4) compared with the C-MAC® (7%, C&L grade 3 and 4) (P < 0.0001). CONCLUSION: Use of the C-MAC® video laryngoscope improved laryngeal imaging and improved the intubating success rate on the first attempt in patients with predictors for difficult intubation in the ICU setting. Video laryngoscopy seems to be a useful tool in the ICU where potentially difficult endotracheal intubations Discussion Both the DL and C-MAC have similar blades – which has many advantages – similar handling techniques and dynamics but the greatest benefit the C-MAC has over the DL is not the fact that everyone can view the image on the screen but the fact that glottis view can be achieved without achieving alignment of visual axes between anatomical structures to view the cords i.e. the camera


can show you things beyond the tissues when your visual axes is interrupted. This biodynamic advantage can also be viewed as a small disadvantage in patients where special blades or anatomical constraints prevent the DL blade from achieving a view i.e. patients needing straight blade or Glidescope or Airtraq! So in the group of significant difficult airway due to anatomical reasons – C-MAC may theoretically not achieve the advantages.

Verdict (based on evidence viewed) –

It may be time to change ED practice to use C-MAC as standard of approach to intubation and at least in the interim (until enough equipment is sought) for any patient where there is any prediction of difficulty! But ED physicians still need to be adept in use of another back up technique – airtraq or glidescope as there is enough evidence to show that in actual difficult airway scenario the two latter techniques have better success rates than the C-MAC. Departments should set in place procedures to maintain stocks of enough usable costly equipment and accountability structures to ensure smooth transfer of equipment to CSSD and ED.


NOSTOS ALGOS - Blast from the past

Br J Exp Pathol. 1929 June; 10(3): 226–236. PMCID: PMC2048009 On the Antibacterial Action of Cultures of a Penicillium, with Special Reference to their Use in the Isolation of B. influenzæ Alexander Fleming From the Laboratories of the Inoculation Department, St Mary's Hospital, London. Received for publication May 10th, 1929. WHILE working with staphylococcus variants a number of culture-plates were set aside on the laboratory bench and examined from time to time. In the examinations these plates were necessarily exposed to the air and they became contaminated with various micro-organisms. It was noticed that around a large colony of a contaminating mould the staphylococcus colonies became transparent and were obviously undergoing lysis . Subcultures of this mould were made and experiments conducted with a view to ascertaining something of the properties of the bacteriolytic substance which had evidently been formed in the mould culture and which had diffused into the surrounding medium. It was found that broth in which the mould had been grown at room temperature for one or two weeks had acquired marked inhibitory, bactericidal and bacteriolytic properties to many of the more common pathogenic bacteria. CHARACTERS OF THE MOULD. The colony appears as a white fluffy mass which rapidly increases in size and after a few days sporulates, the centre becoming dark green and later in old cultures darkens to almost black. In four or five days a bright yellow colour is produced which diffuses into the medium. In certain conditions a reddish colour can be observed in the growth. In broth the mould grows on the surface as a white fluffy growth changing in a few days to a dark green felted mass. The broth becomes bright yellow and this yellow pigment is not extracted by CHC13. The reaction of the broth becomes markedly alkaline, the pH varying, from 8 5 to 9. Acid is produced in three or four days in glucose and saccharose broth. There is no acid production in 7 days in lactose, allanite or dulcite broth. Growth is slow at 37⁰C. and is most rapid about 200C. No growth is observed under anaerobic conditions. In its morphology this organism is a penicillium and in all its characters it most closely resembles P. rubruan. Biourge (1923) states that he has never found P. rubrum in nature and that it is an " animal de laboratoire." This penicillium is not uncommon in the air of the laboratory.


CONCLUSIO - Journal clubs

Updates from toxicology – from the desk of Dr Gopi Mann New Designer drugs Synthetic cannabinoids (functionally similar to THC-delta9/8) Clinical features/complications Psychoactive (intense 'legal high' - euphoria to paranoia to psychosis) Mild Sympathomimetic-like effects (tachy, hypertension) Neuro (seizures) & Renal (AKI) have been reported Death rare Synthetic cathinones (substitute for cocaine, MDMA, amphetamines) 2 most Active ingredients: 1) MDPV (dopamine & Noradrenalin reuptake inhibitor) 2) Mephedrone (monoamine reuptake inhibitor) increasing serotonin, dopamine & noradrenaline levels Clinical features/complications Psychoactive - 'excited delirium' (paranoia, severe agitation & violent behaviour) Sympathomimetic toxidrome - hyperthermia, tachycardia & hypertension Neuro - seizures, altered LOC Renal - Rhabdo (urinary alkalinisation)/renal failure Compartment synd & coagulation disorders CVS - myocarditis to ACS Multi-organ failure/death (several case reports with methylone) Supportive care, BDZs, cooling measures 2nd line for hypertension - GTN, SNP (avoid beta blockers 'cos of unopposed alpha adrenergic stimulation)

ED journal club article – Presented and critiqued by Dr Mary Ibrahim N Engl J Med 2007; 357:2001-2015November 15, 2007DOI: 10.1056/NEJMoa0706482 Prasugrel versus Clopidogrel in Patients with Acute Coronary Syndromes Wiviott SD, Braunwald E et al for the TRITON–TIMI 38 Investigators CONCLUSIONS In patients with acute coronary syndromes with scheduled percutaneous coronary intervention, prasugrel therapy was associated with significantly reduced rates of ischemic events, including stent thrombosis, but with an increased risk of major bleeding, including fatal bleeding. Overall mortality did not differ significantly between treatment groups. Journal club conclusions –

The study fails to demonstrate an overall benefit but may be more suitable in younger patients (<65

years) and unlikely to end up with CABG in the short-term as there is increased bleeding risk. There

were questions raised whether this drug really addresses the issue of non-responders or whether

prasugrel is merely a more pharmaco-active agent! Study does not address the cost-benefit analysis

of using Prasugrel as a default agent and departments should develop protocols for its use if they

find it appropriate.

http://www.nejm.org/toc/nejm/357/20/


PRÉCIS MENSTRUA

Cochrane Database of Systematic Reviews 2013, Issue 2. Art. No.: CD000567. DOI: 10.1002 /14651858.CD000567.pub6. [Intervention Review] Colloids versus crystalloids for fluid resuscitation in critically ill patients Perel P, Roberts I et al Selection criteria Randomised controlled trials (RCTs) of colloids compared to crystalloids, in patients requiring volume replacement. We excluded crossover trials and trials involving pregnant women and neonates. Main results We identified 78 eligible trials; 70 of these presented mortality data. Colloids compared to crystalloids Albumin or plasma protein fraction - 24 trials reported data on mortality, including a total of 9920 patients. The pooled risk ratio (RR) from these trials was 1.01 (95% confidence interval (CI) 0.93 to 1.10). When we excluded the trial with poor-quality allocation concealment, pooled RR was 1.00 (95% CI 0.92 to 1.09). Hydroxyethyl starch - 25 trials compared hydroxyethyl starch with crystalloids and included 9147 patients. The pooled RR was 1.10 (95% CI 1.02 to 1.19). Modified gelatin - 11 trials compared modified gelatin with crystalloid and included 506 patients. The pooled RR was 0.91 (95% CI 0.49 to 1.72). (When the trials by Boldt et al were removed from the three preceding analyses, the results were unchanged.) Dextran - nine trials compared dextran with a crystalloid and included 834 patients. The pooled RR was 1.24 (95% CI 0.94 to 1.65). Colloids in hypertonic crystalloid compared to isotonic crystalloid Nine trials compared dextran in hypertonic crystalloid with isotonic crystalloid, including 1985 randomised participants. Pooled RR for mortality was 0.91 (95% CI 0.71 to 1.06). Authors’ conclusions There is no evidence from randomised controlled trials that resuscitation with colloids reduces the risk of death, compared to resuscitation with crystalloids, in patients with trauma, burns or following surgery. Furthermore, the use of hydroxyethyl starch might increase mortality. As colloids are not associated with an improvement in survival and are considerably more expensive than crystalloids, it is hard to see how their continued use in clinical practice can be justified. Pediatrics peds.2012-3418; published ahead of print April 22, 2013,doi:10.1542/peds.2012-3418 Ingesting and Aspirating Dry Cinnamon by Children and Adolescents: The “Cinnamon Challenge” Grant-Alfieri A, Schaechter J et al The “Cinnamon Challenge” entails swallowing a tablespoon of ground cinnamon in 60 seconds without drinking fluids. However, as stated on www.cinnamonchallenge.com, this challenge is practically impossible, decidedly unpleasant, and potentially harmful. Videos of people attempting the Cinnamon Challenge have become an Internet sensation. Typically, a video reveals a group of adolescents watching as someone taking the challenge begins coughing and choking when the spice triggers a severe gag reflex in response to a caustic sensation in the mouth and throat. As of August 10, 2012, there were 51 100 YouTube clips depicting the Cinnamon Challenge. One video was viewed >19 million times, predominantly by 13- to 24-year-olds, ages similar to people taking the Cinnamon Challenge and associated with the greatest need for conformity. These videos have raised concerns of choking, aspiration, and pulmonary damage. In most cases, the effects are temporary, yet the Cinnamon Challenge has led to dozens of calls to poison centres, emergency department visits, and even hospitalizations for adolescents requiring ventilator support for collapsed lungs Pediatrics. 2013 Mar;131(3):e964-99. doi: 10.1542/peds.2012-3488. Epub 2013 Feb 25. The diagnosis and management of acute otitis media.


Lieberthal AS, Carroll AE et al. Key Action Statement : Clinicians should diagnose acute otitis media (AOM) in children who present with moderate to severe bulging of the tympanic membrane (TM) or new onset of otorrhea not due to acute otitis externa. Evidence Quality: Grade B. Strength: Recommendation. Key Action Statement : Clinicians should not diagnose AOM in children who do not have middle ear effusion (MEE) (based on pneumatic otoscopy and/or tympanometry). Evidence Quality: Grade B. Strength: Recommendation. Key Action Statement: The management of AOM should include an assessment of pain. If pain is present, the clinician should recommend treatment to reduce pain. Evidence Quality: Grade B. Strength: Strong Recommendation. Key Action Statement : Severe AOM: The clinician should prescribe antibiotic therapy for AOM (bilateral or unilateral) in children 6 months and older with severe signs or symptoms (i.e., moderate or severe otalgia or otalgia for at least 48 hours or temperature 39°C [102.2°F] or higher). Evidence Quality: Grade B. Strength: Strong Recommendation. Key Action Statement : Non-severe bilateral AOM in young children: The clinician should prescribe antibiotic therapy for bilateral AOM in children 6 months through 23 months of age without severe signs or symptoms (ie, mild otalgia for less than 48 hours and temperature less than 39°C [102.2°F]). Evidence Quality: Grade B. Strength: Recommendation. Key Action Statement : Nonsevere AOM in older children: The clinician should either prescribe antibiotic therapy or offer observation with close follow-up based on joint decision-making with the parent(s)/caregiver for AOM (bilateral or unilateral) in children 24 months or older without severe signs or symptoms (ie, mild otalgia for less than 48 hours and temperature less than 39°C [102.2°F]). When observation is used, a mechanism must be in place to ensure follow-up and begin antibiotic therapy if the child worsens or fails to improve within 48 to 72 hours of onset of symptoms. Evidence Quality: Grade B. Strength: Recommendation. Key Action Statement : Clinicians should prescribe amoxicillin for AOM when a decision to treat with antibiotics has been made and the child has not received amoxicillin in the past 30 days or the child does not have concurrent purulent conjunctivitis or the child is not allergic to penicillin. Evidence Quality: Grade B. Strength: Recommendation. Key Action Statement: Clinicians should prescribe an antibiotic with additional β-lactamase coverage for AOM when a decision to treat with antibiotics has been made, and the child has received amoxicillin in the last 30 days or has concurrent purulent conjunctivitis, or has a history of recurrent AOM unresponsive to amoxicillin. Evidence Quality: Grade C. Strength: Recommendation. Key Action Statement : Clinicians should not prescribe prophylactic antibiotics to reduce the frequency of episodes of AOM in children with recurrent AOM. Evidence Quality: Grade B. Strength: Recommendation. Key Action Statement : Clinicians may offer tympanostomy tubes for recurrent AOM (3 episodes in 6 months or 4 episodes in 1 year with 1 episode in the preceding 6 months). Evidence Quality: Grade B. Strength: Option. Key Action Statement : Clinicians should encourage exclusive breastfeeding for at least 6 months. Evidence Quality: Grade B. Strength: Recommendation. Key Action Statement: Clinicians should encourage avoidance of tobacco smoke exposure. Evidence Quality: Grade C. Strength: Recommendation. Mayo Clin Proc. 2013 Feb;88(2):149-56. Safety of clopidogrel in hip fracture surgery. Feely MA, Mabry TM et al. RESULTS: Perioperative bleeding complications and mortality were not significantly different between patients who were and were not taking clopidogrel at the time of hip fracture surgery. Combined bleeding outcome criteria was met in 48% of the clopidogrel cohort and 45% of the control cohort (relative


risk, 1.06; 95% CI, 0.70-1.58; P=.80). One-year mortality was 28% in the clopidogrel cohort and 29% in the control cohort (hazard ratio, 1.33; 95% CI, 0.84-2.12; P=.23). CONCLUSION: Although the small sample size precludes making a definitive conclusion, we found no evidence that prompt surgical treatment of hip fracture in patients taking clopidogrel compromises perioperative outcomes. JAMA Intern Med. 2013;():1-8. doi:10.1001/jamainternmed.2013.3795. Nonbenzodiazepine Sleep Medication Use and Hip Fractures in Nursing Home Residents S Berry, Y Lee et al Conclusions and Relevance The risk for hip fracture is elevated among nursing home residents using a nonbenzodiazepine hypnotic drug. New users and residents having mild to moderate cognitive impairment or requiring limited assistance with transfers may be most vulnerable to the use of these drugs. Caution should be exercised when prescribing sleep medications to nursing home residents. N Engl J Med. 2013 Mar 14;368(11):1019-26. doi: 10.1056/NEJMoa1200657. Long-term outcomes in elderly survivors of in-hospital cardiac arrest. Chan PS, Nallamothu BK et al American Heart Association Get with the Guidelines–Resuscitation Investigators. RESULTS: One year after hospital discharge, 58.5% of the patients were alive, and 34.4% had not been readmitted to the hospital. The risk-adjusted rate of 1-year survival was lower among older patients than among younger patients (63.7%, 58.6%, and 49.7% among patients 65 to 74, 75 to 84, and ≥85 years of age, respectively; P<0.001), among men than among women (58.6% vs. 60.9%, P=0.03), and among black patients than among white patients (52.5% vs. 60.4%, P=0.001). The risk-adjusted rate of 1-year survival was 72.8% among patients with mild or no neurologic disability at discharge, as compared with 61.1% among patients with moderate neurologic disability, 42.2% among those with severe neurologic disability, and 10.2% among those in a coma or vegetative state (P<0.001 for all comparisons). Moreover, 1-year readmission rates were higher among patients who were black, those who were women, and those who had substantial neurologic disability (P<0.05 for all comparisons). These differences in survival and readmission rates persisted at 2 years. At 3 years, the rate of survival among survivors of in-hospital cardiac arrest was similar to that of patients who had been hospitalized with heart failure and were discharged alive (43.5% and 44.9%, respectively; risk ratio, 0.98; 95% confidence interval, 0.95 to 1.02; P=0.35). CONCLUSIONS: Among elderly survivors of in-hospital cardiac arrest, nearly 60% were alive at 1 year, and the rate of 3-year survival was similar to that among patients with heart failure. (Funded by the American Heart Association and the National Heart, Lung, and Blood Institute.). Special education topic – Solitary Lung Nodule – there are two articles published in the Chest journal, which are very educational and informative. They are free for download from the website so feel free to read through it. It would be an interesting read for all trainees/ residents pursuing medical/ radiology careers. Chest. 2013 Mar 1;143(3):825-39. doi: 10.1378/chest.12-0960. A practical algorithmic approach to the diagnosis and management of solitary pulmonary nodules: part 1: radiologic characteristics and imaging modalities. Patel VK, Naik SK et al. Abstract The solitary pulmonary nodule (SPN) is frequently encountered on chest imaging and poses an important diagnostic challenge to clinicians. The differential diagnosis is broad, ranging from benign granulomata and infectious processes to malignancy. Important concepts in the evaluation of SPNs


include the definition, morphologic characteristics via appropriate imaging modalities, and the calculation of pretest probability of malignancy. Morphologic differentiation of SPN into solid or subsolid types is important in the choice of follow-up and further management. In this first part of a two-part series, we describe the morphologic characteristics and various imaging modalities available to further characterize SPN. In Part 2, we will describe the determination of pretest probability of malignancy and an algorithmic approach to the diagnosis of SPN. Chest. 2013 Mar 1;143(3):840-6. doi: 10.1378/chest.12-1487. A practical algorithmic approach to the diagnosis and management of solitary pulmonary nodules: part 2: pretest probability and algorithm. Patel VK, Naik SK et al. Abstract In this second part of a two-part series, we describe an algorithmic approach to the diagnosis of the solitary pulmonary nodule (SPN). An essential aspect of the evaluation of SPN is determining the pretest probability of malignancy, taking into account the significant medical history and social habits of the individual patient, as well as morphologic characteristics of the nodule. Because pretest probability plays an important role in determining the next step in the evaluation, we describe various methods the physician may use to make this determination. Subsequently, we outline a simple yet comprehensive algorithm for diagnosing a SPN, with distinct pathways for the solid and subsolid SPN. Chest. 2013; 143(3):672-677. doi:10.1378/chest.12-1095 What Do You Mean, a Spot?:A Qualitative Analysis of Patients’ Reactions to Discussions With Their Physicians About Pulmonary Nodules RS Wiener, MK Gould et al Results: Patients described conversations with 53 different providers about the pulmonary nodule. Almost all patients immediately assumed that they had cancer when first told about the nodule. Some whose providers did not discuss the actual cancer risk or explain the evaluation plan experienced confusion and distress that sometimes lasted for months. Patients were frustrated when their providers did not address their concerns about cancer or potential adverse effects of surveillance (e.g., prolonged uncertainty, radiation exposure), which in some cases led to poor adherence to evaluation plans. Patients found it helpful when physicians used lay terms, showed the CT image, and quantified cancer risk. By contrast, patients resented medical jargon and dismissive language. Conclusions: Patients commonly assume that a pulmonary nodule means cancer. What providers tell (or do not tell) patients about their cancer risk and the evaluation plan can strongly influence patients’ perceptions of the nodule and related distress. We describe simple communication strategies that may help patients to come to terms with an indeterminate pulmonary nodule. Ann Intern Med. 2013 Feb 5;158(3):162-8. The association between midlife cardiorespiratory fitness levels and later-life dementia: a cohort study. Defina LF, Willis BL et al RESULTS: 1659 cases of incident all-cause dementia occurred during 125 700 person-years of Medicare follow-up (median follow-up, 25 years [interquartile range, 19 to 30 years]). After multivariable adjustment, participants in the highest quintile of fitness level had lower hazard of all-cause dementia than those in the lowest quintile (hazard ratio, 0.64 [95% CI, 0.54 to 0.77]). Higher fitness levels were associated with lower hazard of all-cause dementia with previous stroke (hazard ratio, 0.74 [CI, 0.53 to 1.04]) or without previous stroke (hazard ratio, 0.74 [CI, 0.61 to 0.90]). CONCLUSION:


Higher midlife fitness levels seem to be associated with lower hazards of developing all-cause dementia later in life. The magnitude and direction of the association were similar with or without previous stroke, suggesting that higher fitness levels earlier in life may lower risk for dementia later in life, independent of cerebrovascular disease. JAMA Intern Med. 2013;173(6):407-416. doi:10.1001/jamainternmed.2013.2762. Reassurance After Diagnostic Testing With a Low Pretest Probability of Serious Disease Systematic Review and Meta-analysis Alexandra Rolfe, Christopher Burton Results Fourteen randomized controlled trials that included 3828 patients met the inclusion criteria and were analysed with outcomes categorized as short term (≤3 months) or long term (>3 months). Three trials showed no overall effect of diagnostic tests on illness worry (odds ratio, 0.87 [95% CI, 0.55-1.39]), and 2 showed no effect on nonspecific anxiety (standardized mean difference, 0.06 [−0.16 to 0.28]). Ten trials showed no overall long-term effect on symptom persistence (odds ratio, 0.99 [95% CI, 0.85-1.15]). Eleven trials measured subsequent primary care visits. Conclusions and Relevance Diagnostic tests for symptoms with a low risk of serious illness do little to reassure patients, decrease their anxiety, or resolve their symptoms, although the tests may reduce further primary care visits. Further research is needed to maximize reassurance from medically necessary tests and to develop safe strategies for managing patients without testing when an abnormal result is unlikely. JAMA Intern Med. 2013;173(6):416-417. doi:10.1001/jamainternmed.2013.11. Diagnostic Testing and the Illusory Reassurance of Normal Results Comment on “Reassurance After Diagnostic Testing With a Low Pretest Probability of Serious Disease” Kurt Kroenke, MD Cochrane Database Syst Rev. 2012 Dec 12;12:CD010257. doi: 10.1002/14651858.CD010257. Antibiotics for exacerbations of chronic obstructive pulmonary disease. Vollenweider DJ, Jarrett H et al. AUTHORS' CONCLUSIONS: Antibiotics for COPD exacerbations showed large and consistent beneficial effects across outcomes of patients admitted to an ICU. However, for outpatients and inpatients the results were inconsistent. The risk for treatment failure was significantly reduced in both inpatients and outpatients when all trials (1957 to 2012) were included but not when the analysis for outpatients was restricted to currently used antibiotics. Also, antibiotics had no statistically significant effect on mortality and length of hospital stay in inpatients and almost no data on patient-reported outcomes exist. These inconsistent effects call for research into clinical signs and biomarkers that help identify patients who benefit from antibiotics and patients who experience no effect, and in whom downsides of antibiotics (side effects, costs and multi-resistance) could be avoided. Pediatrics. 2013 Mar;131(3):e797-804. doi: 10.1542/peds.2012-1892. Epub 2013 Feb 25. Chest compression quality over time in pediatric resuscitations. Badaki-Makun O, Nadel F et al. RESULTS: A total of 88 484 compression cycles were analysed. Percent adequate CCs/epoch (rate ≥ 100/minute, depth ≥ 38 mm) fell over 10 minutes (child: from 85.1% to 24.6%, adult: from 86.3% to 35.3%; P = .15) and were <70% in both by 2 minutes. Peak work per compression cycle was 13.1 J in the child and 14.3 J in the adult (P = .06; difference, 1.2 J; 95% confidence interval, -0.05 to 2.5). Peak power output was 144.1 W in the child and 166.5 W in the adult (P < .001; difference, 22.4 W, 95% confidence interval, 9.8-35.0). CONCLUSIONS:


CC quality deteriorates similarly in child and adult manikin models. Peak work per compression cycle is comparable in both. Peak power output is analogous to that generated during intense exercise such as running. CC providers should switch every 2 minutes as recommended by current guidelines. BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f1169 (Published 26 March 2013) Association between maternal serum 25-hydroxyvitamin D level and pregnancy and neonatal outcomes: systematic review and meta-analysis of observational studies F Aghajafari, T Nagulesapillai et al Results 3357 studies were identified and reviewed for eligibility. 31 eligible studies were included in the final analysis. Insufficient serum levels of 25-OHD were associated with gestational diabetes (pooled odds ratio 1.49, 95% confidence interval 1.18 to 1.89), pre-eclampsia (1.79, 1.25 to 2.58), and small for gestational age infants (1.85, 1.52 to 2.26). Pregnant women with low serum 25-OHD levels had an increased risk of bacterial vaginosis and low birth weight infants but not delivery by caesarean section. Conclusion Vitamin D insufficiency is associated with an increased risk of gestational diabetes, pre-eclampsia, and small for gestational age infants. Pregnant women with low 25-OHD levels had an increased risk of bacterial vaginosis and lower birth weight infants, but not delivery by caesarean section. JAMA. 2013;309(12):1241-1250. doi:10.1001/jama.2013.2107. Effect of Disodium EDTA Chelation Regimen on Cardiovascular Events in Patients With Previous Myocardial Infarction The TACT Randomized Trial GA Lamas, C Goertz et al for the TACT Investigators Double-blind, placebo-controlled, 2 × 2 factorial randomized trial enrolling 1708 patients aged 50 years or older who had experienced a myocardial infarction (MI) at least 6 weeks prior and had serum creatinine levels of 2.0 mg/dL or less. Participants were recruited at 134 US and Canadian sites. Interventions Patients were randomized to receive 40 infusions of a 500-mL chelation solution (3 g of disodium EDTA, 7 g of ascorbate, B vitamins, electrolytes, procaine, and heparin) (n=839) vs. placebo (n=869) and an oral vitamin-mineral regimen vs. an oral placebo. Infusions were administered weekly for 30 weeks, followed by 10 infusions 2 to 8 weeks apart. Fifteen percent discontinued infusions (n=38 [16%] in the chelation group and n=41 [15%] in the placebo group) because of adverse events. Conclusions and Relevance Among stable patients with a history of MI, use of an intravenous chelation regimen with disodium EDTA, compared with placebo, modestly reduced the risk of adverse cardiovascular outcomes, many of which were revascularization procedures. These results provide evidence to guide further research but are not sufficient to support the routine use of chelation therapy for treatment of patients who have had an MI. The Journal of Emergency Medicine J Emerg Med. 2013;44(2):457-466. Alternative Treatments of Pneumothorax ZD Repanshek, JW Ufberg et al Conclusions: The practices of observation, simple aspiration, and small-bore catheter insertion with Heimlich valve for selected patients may decrease complications, time, and costs by avoiding invasive procedures and hospital admissions. Clinics in Chest Medicine Volume 34, Issue 1 (March, 2013) article in press Straightening Out Chest Tubes - What Size, What Type, and When K Mahmood, MM Wahidi KEY POINTS


Although chest tubes range in size (6–40 French [Fr]) and shape (straight tubes vs. pigtail catheters), small-bore tubes (<14 Fr) are effective for most pleural processes.

Various types of pneumothorax and malignant and infected complicated pleural effusions have been successfully managed with small-bore chest tubes. Benefits of the smaller size include patient comfort and ease of placement.

Large-bore chest tubes may be necessary for barotrauma-associated pneumothoraces in mechanically ventilated patients and in the postoperative setting. However, abundant literature supports a paradigm shift towards the more routine use of small-bore chest tubes for managing pleural disease.

The Seldinger technique can be used for placement of small and large-bore chest tubes and ultrasound guidance is recommended.

Mayo Clinic Proceedings - Volume 88, Issue 3 (March 2013) The Medical Marriage: A National Survey of the Spouses/Partners of US Physicians Results Of the 1644 spouses/partners of physicians surveyed, 891 (54.2%) responded. Most spouses/partners (86.8%) reported that they were satisfied with their relationship with their physician partner. Satisfaction strongly related to the amount of time spent awake with their physician partners each day. Despite their overall satisfaction, spouses/partners reported their physician partners frequently came home irritable, too tired to engage in home activities, or preoccupied with work. On multivariate analysis, minutes spent awake with their physician partners each day was the strongest predictor of relationship satisfaction, exhibiting a dose-response effect. No professional characteristic of the physician partners (e.g., hours worked per week, specialty area, and practice setting) other than the number of nights on call per week correlated with relationship satisfaction on adjusted analysis. Conclusion The spouses/partners of US physicians report generally high satisfaction with their relationships. The mean time spent with their physician partners each day appears to be a dominant factor associated with relationship satisfaction and overshadows any specific professional characteristic of the physicians' practice, including specialty area, practice setting, and work hours. Annals of Emergency Medicine - Volume 61, Issue 4 (April 2013) Ultrasonographically Guided Peripheral Intravenous Cannulation of Children and Adults: A Systematic Review and Meta-analysis Results We identified 4,664 citations, assessed 403 full texts for eligibility, and included 9 trials. Five had low risk, 1 high risk, and 3 unclear risk of bias. A pediatric ED trial found that ultrasonography decreased mean difference (MD) in the number of attempts (MD −2.00; 95% confidence interval [CI] −2.73 to −1.27) and procedure time (MD −8.10 minutes; 95% CI −12.48 to −3.72 minutes). In an operating room pediatric trial, ultrasonography decreased risk of first-attempt failure (risk ratio 0.23; 95% CI 0.08 to 0.69), number of attempts (MD −1.50; 95% CI −2.52 to −0.48), and procedure time (MD −5.95; 95% CI −10.21 to −1.69). Meta-analysis of adult ED trials suggests that ultrasonography decreases the number of attempts (MD −0.43; 95% CI −0.81 to −0.05). Ultrasonography decreased risk of failure (risk ratio 0.47; 95% CI 0.26 to 0.87) in an adult ICU trial. Conclusion Ultrasonography may decrease peripheral intravenous cannulation attempts and procedure time in children in ED and operating room settings. Few outcomes reached statistical significance. Larger well-controlled trials are needed. Annals of Emergency Medicine - Article in Press Effect of Emergency Department Crowding on Outcomes of Admitted Patients


BC Sun, RY Hsia et al Results We studied 995,379 ED visits resulting in admission to 187 hospitals. Patients who were admitted on days with high ED crowding experienced 5% greater odds of inpatient death (95% confidence interval [CI] 2% to 8%), 0.8% longer hospital length of stay (95% CI 0.5% to 1%), and 1% increased costs per admission (95% CI 0.7% to 2%). Excess outcomes attributable to periods of high ED crowding included 300 inpatient deaths (95% CI 200 to 500 inpatient deaths), 6,200 hospital days (95% CI 2,800 to 8,900 hospital days), and $17 million (95% CI $11 to $23 million) in costs. Conclusion Periods of high ED crowding were associated with increased inpatient mortality and modest increases in length of stay and costs for admitted patients. JAMA Intern Med. 2013;():1-10. doi:10.1001/jamainternmed.2013.122. Use of Glucocorticoids and Risk of Venous Thromboembolism A Nationwide Population-Based Case-Control Study SA Johannesdottir, E Horváth-Puhó, et al Results Systemic glucocorticoids increased VTE risk among present (adjusted IRR, 2.31; 95% CI, 2.18-2.45), new (3.06; 2.77-3.38), continuing (2.02; 1.88-2.17), and recent (1.18; 1.10-1.26) users but not among former users (0.94; 0.90-0.99). The adjusted IRR increased from 1.00 (95% CI, 0.93-1.07) for a prednisolone-equivalent cumulative dose of 10 mg or less to 1.98 (1.78-2.20) for more than 1000 to 2000 mg, and to 1.60 (1.49-1.71) for doses higher than 2000 mg. New use of inhaled (adjusted IRR, 2.21; 95% CI, 1.72-2.86) and intestinal-acting (2.17; 1.27-3.71) glucocorticoids also increased VTE risk. Conclusions and Relevance The risk of VTE is increased among glucocorticoid users. Although residual confounding may partly explain this finding, we consider a biological mechanism likely because the association followed a clear temporal gradient, persisted after adjustment for indicators of severity of underlying disease, and existed also for noninflammatory conditions. Hence, our observations merit clinical attention. N Engl J Med 2013; 368:513-523February 7, 2013 DOI: 10.1056/NEJMoa1111096 Rivaroxaban for Thromboprophylaxis in Acutely Ill Medical Patients AT Cohen, TE Spiro et al for the MAGELLAN Investigators RESULTS A total of 8101 patients underwent randomization. A primary efficacy outcome event occurred in 78 of 2938 patients (2.7%) receiving rivaroxaban and 82 of 2993 patients (2.7%) receiving enoxaparin at day 10 (relative risk with rivaroxaban, 0.97; 95% confidence interval [CI], 0.71 to 1.31; P=0.003 for noninferiority) and in 131 of 2967 patients (4.4%) who received rivaroxaban and 175 of 3057 patients (5.7%) who received enoxaparin followed by placebo at day 35 (relative risk, 0.77; 95% CI, 0.62 to 0.96; P=0.02). A principal safety outcome event occurred in 111 of 3997 patients (2.8%) in the rivaroxaban group and 49 of 4001 patients (1.2%) in the enoxaparin group at day 10 (P<0.001) and in 164 patients (4.1%) and 67 patients (1.7%) in the respective groups at day 35 (P<0.001). CONCLUSIONS In acutely ill medical patients, rivaroxaban was noninferior to enoxaparin for standard-duration thromboprophylaxis. Extended-duration rivaroxaban reduced the risk of venous thromboembolism. Rivaroxaban was associated with an increased risk of bleeding. (Funded by Bayer HealthCare Pharmaceuticals and Janssen Research and Development; MAGELLAN ClinicalTrials.gov number,NCT00571649.) Note though non-inferior to enoxaparin, in long term use the risk of haemorrhage with Rivaroxaban was even more than double! Cancer. doi: 10.1002/cncr.27881 Amiodarone and the risk of cancer. Su VY, Hu YW et al

http://clinicaltrials.gov/show/NCT00571649


RESULTS The study included 6418 subjects, with a median follow-up of 2.57 years. A total of 280 patients developed cancer. The risk of cancer increased with borderline significance (SIR, 1.12; 95% confidence interval [95% CI], 0.99-1.26 [P = .067]). Male patients had a higher risk (SIR, 1.18; 95% CI, 1.02-1.36 [P = .022]). The total cohort of patients and the male patients with > 180 cDDDs within the first year were found to have SIRs of 1.28 (95% CI, 1.00-1.61; P = .046) and 1.46 (95% CI, 1.11-1.89; P = .008), respectively. After adjustment for age, sex, and comorbidities, the hazards ratio was 1.98 (95% CI, 1.22-3.22; P = .006) for the high tertile of cDDDs compared with the low tertile. CONCLUSIONS The results of the current study indicate that amiodarone may be associated with an increased risk of incident cancer, especially in males, with a dose-dependent effect. Cancer Causes & Control April 2013 Exposure to pesticides and the risk of childhood brain tumours Greenop KR, Peters S et al Results The odds ratios (ORs) for professional pest control treatments in the home in the year before the index pregnancy, during the pregnancy, and after the child’s birth were 1.54 (95 % confidence interval (CI): 1.07, 2.22), 1.52 (95 % CI: 0.99, 2.34) and 1.04 (95 % CI: 0.75, 1.43), respectively. ORs for treatments exclusively before pregnancy and during pregnancy were 1.90 (95 % CI: 1.08, 3.36) and 1.02 (95 % CI: 0.35, 3.00), respectively. The OR for the father being home during the treatment was 1.79 (95 % CI: 0.85, 3.80). The OR for paternal occupational exposure in the year before the child’s conception was 1.36 (95 % CI: 0.66, 2.80). ORs for prenatal home pesticide exposure were elevated for low- and high-grade gliomas; effect estimates for other CBT subtypes varied and lacked precision. Conclusions These results suggest that preconception pesticide exposure, and possibly exposure during pregnancy, is associated with an increased CBT risk. It may be advisable for both parents to avoid pesticide exposure during this time. JAMA. 2013 Apr 3;309(13):1368-78. doi: 10.1001/jama.2013.3010. Effect of an investigational vaccine for preventing Staphylococcus aureus infections after cardiothoracic surgery: a randomized trial. Fowler VG, Allen KB et al. CONCLUSIONS AND RELEVANCE: Among patients undergoing cardiothoracic surgery with median sternotomy, the use of a vaccine against S. aureus compared with placebo did not reduce the rate of serious postoperative S. aureus infections and was associated with increased mortality among patients who developed S. aureus infections. These findings do not support the use of the V710 vaccine for patients undergoing surgical interventions. Clin Infect Dis. 2013 May;56(9):1261-8. doi: 10.1093/cid/cit052. Epub 2013 Feb 7. Ampicillin Plus Ceftriaxone Is as Effective as Ampicillin Plus Gentamicin for Treating Enterococcus faecalis Infective Endocarditis. Fernández-Hidalgo N, Almirante B et al. A larger percentage of AC-treated patients (n = 159) had previous chronic renal failure than AG-treated patients (n = 87) (33% vs. 16%, P = .004), and AC patients had a higher incidence of cancer (18% vs. 7%, P = .015), transplantation (6% vs. 0%, P = .040), and healthcare-acquired infection (59% vs. 40%, P = .006). Between AC and AG-treated EFIE patients, there were no differences in mortality while on antimicrobial treatment (22% vs. 21%, P = .81) or at 3-month follow-up (8% vs. 7%, P = .72), in treatment failure requiring a change in antimicrobials (1% vs. 2%, P = .54), or in relapses (3% vs. 4%, P = .67). However, interruption of antibiotic treatment due to adverse events was much more


frequent in AG-treated patients than in those receiving AC (25% vs. 1%, P < .001), mainly due to new renal failure (≥25% increase in baseline creatinine concentration; 23% vs. 0%, P < .001). Conclusions. AC appears as effective as AG for treating EFIE patients and can be used with virtually no risk of renal failure and regardless of the high-level aminoglycoside resistance status of E. faecalis. BMJ. 2013 Mar 25;346:f1654. doi: 10.1136/bmj.f1654. Coronary artery calcium score prediction of all-cause mortality and cardiovascular events in people with type 2 diabetes: systematic review and meta-analysis. Kramer CK, Zinman B et al. CONCLUSION: In people with type 2 diabetes, a coronary artery calcium score of ≥10 predicts all-cause mortality or cardiovascular events, or both, and cardiovascular events alone, with high sensitivity but low specificity. Clinically, the finding of a coronary artery calcium score of <10 may facilitate risk stratification by enabling the identification of people at low risk within this high risk population. J Infect Dis. 2013 Apr;207(7):1037-46. doi: 10.1093/infdis/jis773. Epub 2013 Jan 30. Exposure to influenza virus aerosols during routine patient care. This despite surgical mask use! Bischoff WE, Swett K, et al. METHODS: During the 2010-2011 influenza season, subjects with influenza-like illness were enrolled in an emergency department and throughout a tertiary care hospital, nasopharyngeal swab specimens were obtained, and symptom severity, treatment, and medical history were recorded. Quantitative impaction air samples were taken not ≤0.305 m (1 foot), 0.914 m (3 feet), and 1.829 m (6 feet) from the patient's head during routine care. Influenza virus was detected by rapid test and polymerase chain reaction. RESULTS: Sixty-one of 94 subjects (65%) tested positive for influenza virus. Twenty-six patients (43%) released influenza virus into room air, with 5 (19%) emitting up to 32 times more virus than others. Emitters surpassed the airborne 50% human infectious dose of influenza virus at all sample locations. Healthcare professionals (HCPs) were exposed to mainly small influenza virus particles (diameter, <4.7 µm), with concentrations decreasing with increasing distance from the patient's head (P < .05). Influenza virus release was associated with high viral loads in nasopharyngeal samples (shedding), coughing, and sneezing (P < .05). Patients who reported severe illness and major interference with daily life also emitted more influenza virus (P < .05). CONCLUSIONS: HCPs within 1.829 m of patients with influenza could be exposed to infectious doses of influenza virus, primarily in small-particle aerosols. This finding questions the current paradigm of localized droplet transmission during non-aerosol-generating procedures. Nat Med http://dx.doi.org/10.1038/nm.3145 Intestinal microbiota metabolism of l-carnitine, a nutrient in red meat, promotes atherosclerosis Koeth RA, Wang Z et al Intestinal microbiota metabolism of choline and phosphatidylcholine produces trimethylamine (TMA), which is further metabolized to a proatherogenic species, trimethylamine-N-oxide (TMAO). We demonstrate here that metabolism by intestinal microbiota of dietary L-carnitine, a trimethylamine abundant in red meat, also produces TMAO and accelerates atherosclerosis in mice. Omnivorous human subjects produced more TMAO than did vegans or vegetarians following ingestion of L-carnitine through a microbiota-dependent mechanism. The presence of specific bacterial taxa in human faeces was associated with both plasma TMAO concentration and dietary status. Plasma L-carnitine levels in subjects undergoing cardiac evaluation (n = 2,595) predicted


increased risks for both prevalent cardiovascular disease (CVD) and incident major adverse cardiac events (myocardial infarction, stroke or death), but only among subjects with concurrently high TMAO levels. Chronic dietary L-carnitine supplementation in mice altered cecal microbial composition, markedly enhanced synthesis of TMA and TMAO, and increased atherosclerosis, but this did not occur if intestinal microbiota was concurrently suppressed. In mice with an intact intestinal microbiota, dietary supplementation with TMAO or either carnitine or choline reduced in vivo reverse cholesterol transport. Intestinal microbiota may thus contribute to the well-established link between high levels of red meat consumption and CVD risk. EMS Activation of the Cardiac Catheterization Laboratory Is Associated with Process Improvements in the Care of Myocardial Infarction Patients Cone DC, Lee CH et al Conclusions. In the system studied, EMS field activation of the catheterization laboratory for patients with STEMI is associated with shorter D2B times and better compliance with 90-minute benchmarks than ED activation for either walk-in STEMI patients or STEMI patients arriving by EMS without field activation. Improvements are needed in compliance with the field activation protocol to maximize these benefits. West J Emerg Med 2013;14(2):103-108. Clinician-performed Beside Ultrasound for the Diagnosis of Traumatic Pneumothorax Ku BS, Fields JM. Results: There were 549 patients enrolled. The median injury severity score of the patients was 5 (inter-quartile range [IQR] 1-14); 36 different sonologists performed TUS. Forty-seven of the 549 patients had traumatic PTX, for an incidence of 9%. TUS correctly identified 27/47 patients with PTX for a sensitivity of 57% (confidence interval [CI] 42-72%). There were 3 false positive cases of TUS for a specificity of 99% (CI 98%-100%). A “wet” chest radiograph reading done in the trauma bay showed a sensitivity of 40% (CI 23-59) and a specificity of 100% (99-100). Conclusion: In a large heterogeneous group of clinicians who typically care for trauma patients, the sonographic evaluation for pneumothorax was as accurate as supine chest radiography. Thoracic ultrasound may be helpful in the initial evaluation of patients with truncal trauma. J Trauma Acute Care Surg. 2013 Mar;74(3):780-4. doi: 10.1097/TA.0b013e3182826d5f. The impact of specialist trauma service on major trauma mortality. Wong TH, Lumsdaine W et al. Abstract INTRODUCTION: Trauma services throughout the world have had positive effects on trauma-related mortality. Australian trauma services are generally more consultative in nature rather than the North American model of full trauma admission service. We hypothesized that the introduction of a consultative specialist trauma service in a Level I Australian trauma centre would reduce mortality of the severely injured. CONCLUSION: The introduction of a specialist trauma service decreased the mortality of patients with severe injury, the model of care should be considered to implement state- and nationwide in Australia. N Engl J Med 2013; 368:1272-1274April 4, 2013DOI: 10.1056/NEJMp1302834 Dabigatran and Post marketing Reports of Bleeding Southworth MR, Reichman ME et al for the FDA. We believe that the large number of reported cases of bleeding associated with dabigatran provides a salient example of stimulated reporting. In this case, such reporting provided a distorted estimate of the comparative bleeding rates associated with dabigatran and warfarin in clinical practice. The


Mini-Sentinel assessment suggests that bleeding rates associated with dabigatran are not higher than those with warfarin, a finding that is consistent with the results of RE-LY. Although some have noted the lack of an available reversal agent for the anticoagulant effects of dabigatran as an important limitation of its use, data from RE-LY are reassuring with respect to bleeding. We believe that dabigatran provides an important health benefit when used as directed. Further analysis of the Mini-Sentinel and other claims databases is ongoing, as is routine post marketing surveillance through FAERS. Published online before print March 18, 2013, Neurology 10.1212/WNL.0b013e31828d57dd Summary of evidence-based guideline update: Evaluation and management of concussion in sports Giza CC, Kutcher JS et al The following highlights of the update are helpful to primary care clinicians who care for athletes with concussion on the field or in the office setting:

Concussion risk is greater for female athletes than for male athletes participating in the same sport (e.g., soccer and basketball).

Concussion risk is greater in American football and Australian rugby than in other sports. Head protection probably decreases risk, but no specific type of headgear can be

recommended. Standardized assessment tools (e.g., Post-Concussion Symptom Scale and Standardized

Assessment of Concussion) are relatively accurate in identifying concussion and useful for monitoring resolution of symptoms. These tools are not diagnostic and should only be used as an adjunct to traditional clinical evaluation.

Neuroimaging is not needed unless evidence exists of more severe trauma, clinical deterioration, loss of consciousness, post-traumatic amnesia, or focal neurologic deficits.

The critical objective in caring for concussed athletes is to monitor each athlete to complete resolution of symptoms before allowing them to return to play or practice. High-school age and younger athletes might require more conservative care and longer time to return to play. There is no known treatment that speeds recovery or prevents long-term impairment. Prior concussion predicts future concussions, and that plus prolonged recovery may predict long-term sequelae. BMJ. 2013 Apr 2;346:f1706. doi: 10.1136/bmj.f1706. Clinical prediction model to aid emergency doctors managing febrile children at risk of serious bacterial infections: diagnostic study. Nijman RG, Vergouwe Y et al. RESULTS: Oxygen saturation <94% and presence of tachypnoea were important predictors of pneumonia. A raised C reactive protein level predicted the presence of both pneumonia and other SBIs, whereas chest wall retractions and oxygen saturation <94% were useful to rule out the presence of other SBIs. Discriminative ability (C statistic) to predict pneumonia was 0.81 (95% confidence interval 0.73 to 0.88); for other SBIs this was even better: 0.86 (0.79 to 0.92). Risk thresholds of 10% or more were useful to identify children with serious bacterial infections; risk thresholds less than 2.5% were useful to rule out the presence of serious bacterial infections. External validation showed good discrimination for the prediction of pneumonia (0.81, 0.69 to 0.93); discriminative ability for the prediction of other SBIs was lower (0.69, 0.53 to 0.86). CONCLUSION: A validated prediction model, including clinical signs, symptoms, and C reactive protein level, was useful for estimating the likelihood of pneumonia and other SBIs in children with fever, such as septicaemia/meningitis and urinary tract infections.

BMJ. 2013 Mar 26;346:f1720. doi: 10.1136/bmj.f1720.


Ultrasound imaging for lumbar punctures and epidural catheterisations: systematic review and meta-analysis. Shaikh F, Brzezinski J et al. RESULTS: 14 studies with a total of 1334 patients were included (674 patients assigned to the ultrasound group, 660 to the control group). Five studies evaluated lumbar punctures and nine evaluated epidural catheterisations. Six of 624 procedures conducted in the ultrasound group failed; 44 of 610 procedures in the control group failed. Ultrasound imaging reduced the risk of failed procedures (risk ratio 0.21 (95% confidence interval 0.10 to 0.43), P<0.001). CONCLUSIONS: Ultrasound imaging can reduce the risk of failed or traumatic lumbar punctures and epidural catheterisations, as well as the number of needle insertions and redirections. Ultrasound may be a useful adjunct for these procedures. BMJ. 2013 Mar 18;346:f1140. doi: 10.1136/bmj.f1140. Use of caffeinated substances and risk of crashes in long distance drivers of commercial vehicles: case-control study. Sharwood LN, Elkington J et al. RESULTS: Forty three percent of drivers reported consuming substances containing caffeine, such as tea, coffee, caffeine tablets, or energy drinks for the express purpose of staying awake. Only 3% reported using illegal stimulants such as amphetamine ("speed"); 3,4 methylenedioxymethamphetamine (ecstasy); and cocaine. After adjustment for potential confounders, drivers who consumed caffeinated substances for this purpose had a 63% reduced likelihood of crashing (odds ratio 0.37, 95% confidence interval 0.27 to 0.50) compared with drivers who did not take caffeinated substances. CONCLUSIONS: Caffeinated substances are associated with a reduced risk of crashing for long distance commercial motor vehicle drivers. While comprehensive mandated strategies for fatigue management remain a priority, the use of caffeinated substances could be a useful adjunct strategy in the maintenance of alertness while driving. BMJ. 2013 Mar 18;346:f880. doi: 10.1136/bmj.f880. Use of high potency statins and rates of admission for acute kidney injury: multicentre, retrospective observational analysis of administrative databases. Dormuth CR, Hemmelgarn BR et al. RESULTS: Of more than two million statin users (2 008 003 with non-chronic kidney disease; 59 636 with chronic kidney disease), patients with similar propensity scores were comparable on measured characteristics. Within 120 days of current treatment, there were 4691 hospitalizations for acute kidney injury in patients with non-chronic kidney injury, and 1896 hospitalizations in those with chronic kidney injury. In patients with non-chronic kidney disease, current users of high potency statins were 34% more likely to be hospitalized with acute kidney injury within 120 days after starting treatment (fixed effect rate ratio 1.34, 95% confidence interval 1.25 to 1.43). CONCLUSIONS: Use of high potency statins is associated with an increased rate of diagnosis for acute kidney injury in hospital admissions compared with low potency statins. The effect seems to be strongest in the first 120 days after initiation of statin treatment. Pediatr Emerg Care. 2013 Mar;29(3):337-41. doi: 10.1097/PEC.0b013e31828512a5.


Does bedside sonographic measurement of the inferior vena cava diameter correlate with central venous pressure in the assessment of intravascular volume in children? Ng L, Khine H et al. RESULTS: Of the 51 participants, 21 (43%) had a CVP of 8 mm Hg or less. Eight (16%) of 51 children had a collapsibility index 50% or greater, and 8 (18%) of 43 had an IVC/aorta ratio of 0.8 or less. The sensitivity of a collapsibility index 0.5 or greater to predict a CVP of 8 mm Hg or less was 14%, the specificity was 83%, the positive predictive value was 38%, and the negative predictive value was 57%. Neither collapsibility index (r = -0.23, P = 0.11) nor IVC/aorta (r = -0.19, P = 0.22) correlated with CVP in assessing intravascular volume in our study population. CONCLUSIONS: Based on these data, the IVC and aortic measurements by BUS are not reliable indicators of intravascular volume (as determined by CVP) in acutely ill children. Intensive Care Medicine April 2013 Point-of-care multiorgan ultrasonography for the evaluation of undifferentiated hypotension in the emergency department Volpicelli G., Lamorte A. et al. Abstract Purpose We analysed the efficacy of a point-of-care ultrasonographic protocol, based on a focused multiorgan examination, for the diagnostic process of symptomatic, non-traumatic hypotensive patients in the emergency department. Methods We prospectively enrolled 108 adult patients complaining of non-traumatic symptomatic hypotension of uncertain etiology. Patients received immediate point-of-care ultrasonography to determine cardiac function and right/left ventricle diameter rate, inferior vena cava diameter and collapsibility, pulmonary congestion, consolidations and sliding, abdominal free fluid and aortic aneurysm, and leg vein thrombosis. The organ-oriented diagnoses were combined to formulate an ultrasonographic hypothesis of the cause of hemodynamic instability. The ultrasonographic diagnosis was then compared with a final clinical diagnosis obtained by agreement of three independent expert physicians who performed a retrospective hospital chart review of each case. Results Considering the whole population, concordance between the point-of-care ultrasonography diagnosis and the final clinical diagnosis was interpreted as good, with Cohen’s k = 0.710 (95 % CI, 0.614–0.806), p < 0.0001 and raw agreement (Ra) = 0.768. By eliminating the 13 cases where the final clinical diagnosis was not agreed upon (indefinite), the concordance increased to almost perfect, with k = 0.971 (95 % CI, 0.932–1.000), p < 0.0001 and Ra = 0.978. Conclusions Emergency diagnostic judgments guided by point-of-care multiorgan ultrasonography in patients presenting with undifferentiated hypotension significantly agreed with a final clinical diagnosis obtained by retrospective chart review. The integration of an ultrasonographic multiorgan protocol in the diagnostic process of undifferentiated hypotension has great potential in guiding the first-line therapeutic approach.


Special Mention Article!

doi:10.1073/pnas.1219361110 PNAS April 8, 2013 impact factor is 9.681 Penis size interacts with body shape and height to influence male attractiveness Mautz BS, Wong BBM et al Abstract Compelling evidence from many animal taxa indicates that male genitalia are often under postcopulatory sexual selection for characteristics that increase a male’s relative fertilization success. There could, however, also be direct precopulatory female mate choice based on male genital traits. Before clothing, the nonretractable human penis would have been conspicuous to potential mates. This observation has generated suggestions that human penis size partly evolved because of female choice. Here we show, based upon female assessment of digitally projected life-size, computer-generated images, that penis size interacts with body shape and height to determine male sexual attractiveness. Positive linear selection was detected for penis size, but the marginal increase in attractiveness eventually declined with greater penis size (i.e., quadratic selection). Penis size had a stronger effect on attractiveness in taller men than in shorter men. There was a similar increase in the positive effect of penis size on attractiveness with a more masculine body shape (i.e., greater shoulder-to-hip ratio). Surprisingly, larger penis size and greater height had almost equivalent positive effects on male attractiveness. Our results support the hypothesis that female mate choice could have driven the evolution of larger penises in humans. More broadly, our results show that precopulatory sexual selection can play a role in the evolution of genital traits.


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